ICD-10-CM Conventions

CHAPTER OVERVIEW
 
 A variety of notes appear in ICD-10-CM.

-- General notes commonly provide general information on usage in a specific

section.

-- Inclusion notes and exclusion notes indicate when certain conditions are or

are not included in a subdivision.

-- Additional instructional notes direct the coding professional to create a

complete statement on the condition.
 Two main abbreviations (NEC and NOS) are used in ICD-10-CM.
 Cross-reference notes advise the coding professional to look elsewhere
before assigning a code.
 Punctuation marks and relational terms have a specialized meaning in
ICD-10-CM.

LEARNING OUTCOMES
 
After studying this chapter you should be able to:
 
List the different types of instructional notes.
 
Explain the importance of additional notes to the coding process.
 
Describe the difference between the abbreviations NEC and NOS.
 
Use your knowledge of cross-reference notes to navigate ICD-10-CM.
 
Define the specialized meanings of punctuation marks and relational terms in ICD-10-
CM.

TERMS TO KNOW
 
NEC
not elsewhere classified; used in the Alphabetic Index to indicate that there is no
separate code for the condition even though the diagnostic statement is specific
 
NOS
not otherwise specified; equivalent to the term "unspecified"

REMEMBER
 
These conventions are not just helpful; they are necessary to successful coding.

INTRODUCTION
 
ICD-10-CM follows certain conventions in order to provide large amounts of
information in a succinct and consistent manner. A thorough understanding of these
conventions is fundamental to accurate coding. The conventions and instructions of
the classification are applicable to all health care settings, unless otherwise indicated.
     ICD-10-CM conventions include the following:
 
 Instructional notes
 Abbreviations
 Cross-reference notes
 Punctuation marks
 Relational terms ("and," "with," "without," "due to")

INSTRUCTIONAL NOTES
 
A variety of notes appear as instructions to the coding professional. These include
general notes, inclusion and exclusion notes, "code first" notes, "use additional code"
notes, and "code also" notes.

General Notes
 
     General notes in the Tabular List of Diseases and Injuries provide general
information on usage in a specific section, such as the note under chapter 15 of ICD-
10-CM, Pregnancy, Childbirth and the Puerperium, that explains that codes from this
chapter are for use only on maternal records, never on newborn records.

Inclusion and Exclusion Notes

 
     Codes in a classification system must be mutually exclusive, with no overlapping
of content. In ICD-10-CM, therefore, it is sometimes necessary to indicate when
certain conditions are or are not included in a given subdivision. This is accomplished
by means of inclusion and exclusion notes.
     The location of inclusion and exclusion notes is extremely important. When this
type of note is located at the beginning of a chapter or a section in ICD-10-CM, that
advice applies to all codes within the chapter or section and is not repeated with
individual categories or specific codes. Keep in mind that instructional notes affecting
the code under consideration may be located on a previous page.
 
      Inclusion Notes
     Inclusion notes are introduced by the word "includes" when placed at the
beginning of a chapter or section. Inclusion notes are used to further define, or give
examples of, the content of the chapter, section, or category. Conditions listed in an
inclusion note may be synonyms or conditions similar enough to be classified to the
same code. Inclusion notes are not exhaustive; rather, they list certain conditions to
reassure the coding professional, particularly when the title in the Tabular List may
not seem to apply.
     An example of an inclusion note can be found in the Tabular List, chapter 1,
Certain Infectious and Parasitic diseases (A00-B99). The inclusion note states that this
chapter includes diseases generally recognized as communicable or transmissible.
This note applies to all codes listed from A00 through B99.
     Inclusion notes may also appear immediately under a three-character code title to
further define, or give examples of, the content of the category. An example of this
type of inclusion note can be found in the Tabular List at category D50, Iron
deficiency anemia. The inclusion note states that codes in this category include
asiderotic anemia and hypochromic anemia.
 
     Inclusion Terms
     Lists of terms are included under some codes. The terms are some of the
conditions that may be reported with those codes. The terms may represent terms
synonymous to the code title. In the case of "other specified codes," the terms may be
a list of the various conditions that are assigned to that code. As in the case of the
inclusion notes, the list of inclusion terms is not meant to be exhaustive. The Index
may also list additional terms classified to a code and not repeated as inclusion terms.
 
      Exclusion Notes
     Exclusion notes are introduced by the word "excludes." Excluded conditions are
listed in alphabetical order, with the code number or code range shown in parentheses.
Exclusion notes are the opposite of inclusion notes; they indicate that a particular
condition is not assigned to the code to which the note applies. The basic message of
an excludes note is "code this condition elsewhere."
     There are two types of exclusion notes in ICD-10-CM--each has a different use,
but both indicate that codes excluded are independent of each other.
 
     "Excludes1"
     An "excludes1" note means "NOT CODED HERE!" An "excludes1" note instructs
that the code excluded should never be used at the same time as the code above the
"excludes1" note. This instruction is used when two conditions cannot occur together
and therefore both codes cannot be used together. For example:
 
      Q03 Congenital hydrocephalus
      Excludes1: acquired hydrocephalus (G91.-)
 
In this example, the congenital form of the condition cannot be reported with the
acquired form of the same condition.
     There is an exception to the excludes1 definition when the two conditions are
unrelated to each other. For example, code F45.8, Other somatoform disorders, has
an excludes1 note for "sleep related teeth grinding" (G47.63) because "teeth grinding"
is an inclusion term under F45.8. Only one of these two codes should be assigned for
teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under
F45.8, and a patient could have both this condition and sleep-related teeth grinding. In
this case, the two conditions are clearly unrelated to each other, and so it would be
appropriate to report F45.8 and G47.63 together. If it is not clear whether the two
conditions involving an excludes1 note are related or not, query the provider.
 
     "Excludes2"
     An "excludes2" note means "NOT INCLUDED HERE!" An "excludes2" note
instructs that the condition excluded is not part of the condition represented by the
code. However, a patient may have both conditions at the same time. When an
"excludes2" note appears under a code, it is acceptable to use both the code and the
excluded code together. For example:
 
      F90 Attention-deficit hyperactivity disorders
       Excludes2: anxiety disorders (F40.-, F41.-)
       mood [affective] disorders (F30-F39)
 
In this example, the "excludes2" note serves as a warning that if a patient has an
anxiety disorder, rather than attention-deficit hyperactivity disorder, the user should
go to categories F40-F41 rather than remain in category F90. However, if a patient
has both attention-deficit hyperactivity and an anxiety disorder, a code from category
F90 could be used along with a code from categories F40-F41.

"Code First" and "Use Additional Code"

 
     Certain conditions have both an underlying etiology and multiple body system
manifestations due to the underlying etiology. In the Tabular List, "code first" and
"use additional code" instructional notes indicate the proper sequencing order of these
conditions--etiology (underlying condition) followed by manifestation. The "use
additional code" note is found at the etiology code as a clue to identify the
manifestations commonly associated with the disease. The "code first" note is found
at the manifestation code to provide instructions that the underlying condition, if
present, should be sequenced first.
     The manifestation codes usually have the phrase "in diseases classified elsewhere"
as part of the code title. Codes with this phrase are never used as a first-listed or
principal diagnosis code. For such codes, a "use additional code" note appears at the
etiology code, and a "code first" note appears at the manifestation code. An example
of this convention is category F02, Dementia in other diseases classified elsewhere.
     Other notes of this type provide a list introduced by the phrase "such as," meaning
that any of the listed codes or any other appropriate code can be assigned first.
Code J99, Respiratory disorders in diseases classified elsewhere, provides a list of
conditions that may be the underlying disease.
     It is not necessary to report the code identified in a "use additional code" note in
the diagnosis field immediately following the primary code. There is no strict
hierarchy inherent in the guidelines, nor in the ICD-10-CM classification, regarding
the sequencing of secondary diagnosis codes.

"Code Also"
 
     "Code also" notes in ICD-10-CM indicate that two codes may be required to fully
describe a condition. This note does not provide sequencing direction. The sequencing
order will depend on the reason for the encounter and the severity of the conditions.
An example of this note can be found under code G47.01, Insomnia due to medical
condition, where the instructional note tells us to code also the associated medical
condition.

ABBREVIATIONS
 
ICD-10-CM uses two main abbreviations:
 
 NEC, for not elsewhere classified
 NOS, for not otherwise specified
Although their meanings appear simple, these abbreviations are often misunderstood
and misapplied. It is very important to understand not only their meanings but also
their differences, because they provide guidelines for correct code selection.

NEC
 
     The abbreviation NEC is used in the Alphabetic Index and the Tabular List to
indicate that there is no separate code for the condition even though the diagnostic
statement may be very specific. It is used when the information in the medical record
provides detail for which a specific code does not exist. It represents "other
specified." In the Tabular List, such conditions are ordinarily classified to a code with
a fourth or sixth character 8 (or a fifth character 9) with a title that includes the words
"other specified" or "not elsewhere classified," which permits the grouping of related
conditions to conserve space and limit the size of the classification system. For
example, a disease of the pleura specified as hydropneumothorax is included in
code J94.8, Other specified pleural conditions.

NOS
 
     The abbreviation NOS is the equivalent of "unspecified" and is used in the
Alphabetic Index and the Tabular List. Codes so identified are to be used only when
neither the diagnostic statement nor the medical record provides information that
permits classification to a more specific code. The codes in these cases are ordinarily
classified to codes with a fourth or sixth character 9 (or a fifth character 0); conditions
listed as both "not elsewhere classified" and "unspecified" are sometimes combined in
one code. Note that a main term followed by a list of subterms in the Alphabetic
Index usually displays the unspecified code; the subterms must always be reviewed to
determine whether a more specific code can be assigned.
     For example, the main term Cardiomyopathy displays code I42.9. Subterms such
as "alcoholic" or "congestive" are provided for more specific cardiomyopathies. Code
I42.9 should be assigned only when there is no information in the medical record to
identify one of these subterms.
CROSS-REFERENCE NOTES
 
Cross-reference notes are used in the Alphabetic Index to advise the coding
professional to look elsewhere before assigning a code. The cross-reference
instructions include "see," "see also," "see category," and "see condition."

"See"
 
     The "see" cross-reference indicates that the user must refer to an alternative term.
This instruction is mandatory; coding cannot be completed without following this
advice. For example, the entry for Hemarthrosis, traumatic, uses this cross-reference
to advise the user to reference the entry for "sprain" by site.

"See Also"
 
     The "see also" cross-reference advises the coding professional that there is another
place in the Alphabetic Index that must be referred to when the entries under
consideration do not provide a code for the specific condition or procedure. It is not
necessary to follow this cross-reference when the original entries provide all the
information necessary.
     For example, the cross-reference for the term Psychoneurosis advises the user to
"see also Neurosis" when none of the specific subterms provides a code. To locate the
code for neurasthenic psychoneurosis, it would not be necessary to follow this cross-
reference because there is a subterm "neurasthenic" under the
term Psychoneurosis. If the diagnosis were psychasthenic psychoneurosis, however,
the code could be located only by following the "see also" reference.

"See Category"
 
     The "see category" variation of the "see" cross-reference provides a category
number. The coding professional must refer to that number in the Tabular List and
select a code from the options provided there. For example, a cross-reference under
the Index entry for main term Mononeuropathy, subterm "in diseases classified
elsewhere," refers the user to category G59.

"See Condition"
 
     Occasionally, the Index advises the user to refer to the main term of a condition.
For example, in referencing the main term Arterial for arterial thrombosis, the Index
advice is to "see condition," and the user should then go to the main
term Thrombosis. This cross-reference ordinarily appears when the adjective rather
than the term (in noun form) has been referenced for the condition itself.

PUNCTUATION MARKS
 
Several punctuation marks are used in ICD-10-CM, most of which have a specialized
meaning in addition to the usual English language usage.

Parentheses
 
     Parentheses are used in ICD-10-CM to enclose supplementary words or
explanatory information that may be either present or absent in the statement of
diagnosis without affecting the code to which it is assigned. Such terms are
considered to be "nonessential modifiers" and are used to suggest that the terms in
parentheses are included in the code but need not be stated in the diagnosis. This is a
significant factor in correct code assignment. Terms enclosed in parentheses in either
the Tabular List or the Alphabetic Index do not affect the code assignment in any
way; they serve only as reassurance that the correct code has been located.
     For example, refer to the main term Pneumonia, which has several nonessential
modifiers enclosed in parentheses. Unless a more specific subterm is located, this
code will be assigned for pneumonia described by any of the terms in parentheses.
Diagnoses of acute pneumonia and purulent pneumonia, for example, are both coded
J18.9 because both terms appear in parentheses as nonessential modifiers. Pneumonia
not otherwise specified is also assigned to code J18.9 because none of the terms in
parentheses is required for this code assignment.
     It is important to distinguish between the use of nonessential and essential
modifiers. Essential modifiers are listed as subterms in the Alphabetic Index, not in
parentheses, and they do affect code assignment. In contrast, words in parentheses are
nonessential and do not affect the code assignment. For example, scoliosis described
as acquired or postural is classified as M41.9, as the words "acquired" and "postural"
are nonessential modifiers and do not affect the code; on the other hand, the term
"congenital" is an essential modifier, and the code for this term is Q67.5.
     The nonessential modifiers in the Index to Diseases apply to subterms following a
main term, except when a nonessential modifier and a subentry are mutually
exclusive, in which case the subentry takes precedence. For example, in ICD-10-CM's
Alphabetic Index under the main term Enteritis, "acute" is a nonessential modifier,
and "chronic" is a subentry. In this case, the nonessential modifier "acute" does not
apply to the subentry "chronic."

Square Brackets
 
     Square brackets are often used in the Tabular List to enclose synonyms, alternative
wordings, abbreviations, and explanatory phrases that provide additional
information--for example, human immunodeficiency virus [HIV]. They are similar to
parentheses in that they are not required for the statement of diagnosis. Square
brackets are also used to indicate that the number in the bracket can only be a
manifestation and the other number must be assigned first for the underlying code.
The code in the brackets in this situation indicates that both conditions must be used,
and the code in the brackets can never be assigned as the principal diagnosis. In the
following example from the Alphabetic Index, the first code represents an underlying
disease, and the second code enclosed in brackets represents a manifestation:
 
     Nephropathy . . .
      sickle cell D57.- [N08]

Colons
 
     Colons are used in the Tabular List in both inclusion notes and exclusion notes
after an incomplete term that needs one or more of the modifiers following the colon
in order for the term to apply. The exclusion statement under code N92.6 in the
Tabular List is an example of this usage. Here, the colon following the subterms
"irregular menstruation with" indicates that if it is described as irregular menstruation
with lengthened intervals or scanty bleeding, or irregular menstruation with shortened
intervals or excessive bleeding, code N92.6 is excluded.
 
      N92.6 Irregular menstruation, unspecified
          Irregular bleeding NOS
          Irregular periods NOS
          Excludes1: irregular menstruation with:
          lengthened intervals or scanty bleeding (N91.3-N91.5)
          shortened intervals or excessive bleeding (N92.1)

RELATIONAL TERMS

"And"
 
     The word "and" should be interpreted to mean either "and" or "or" when it appears
in a code title. For example, cases of "tuberculosis of bones," "tuberculosis of joints,"
and "tuberculosis of bones and joints" are classified to subcategory A18.0,
Tuberculosis of bones and joints.

"With" and "In"

 
     The words "with" and "in" should be interpreted to mean "associated with" or "due
to" when they appear in a code title, the Alphabetic Index, or an instructional note in
the Tabular List. The classification presumes a causal relationship between the two
conditions linked by these terms in the Alphabetic Index or the Tabular List. These
conditions should be coded as related even in the absence of provider documentation
explicitly linking them, unless the documentation clearly states the conditions are
unrelated, or unless another guideline exists that specifically requires a documented
linkage between two conditions (for example, a sepsis guideline for "acute organ
dysfunction that is not clearly associated with the sepsis"). For conditions not
specifically linked by these relational terms in the classification, or for situations in
which a guideline requires that a linkage between two conditions be explicitly
documented, provider documentation must link the conditions in order to code them
as related. The word "with" in the Alphabetic Index is sequenced immediately
following the main term and is not in alphabetical order.
     The following example from the Alphabetic Index for the main term Diabetes and
the subterm "with" demonstrates the linkage between conditions:
 
      Diabetes, diabetic (mellitus) (sugar) E11.9
       -with
       --amyotrophy E11.44
       --arthropathy NEC E11.618
       --autonomic (poly) neuropathy E11.43
       --cataract E11.36
       --Charcot's joints E11.610
       --chronic kidney disease E11.22
 
The diagnoses of diabetes and chronic kidney disease are coded as E11.22, Type 2
diabetes mellitus with diabetic chronic kidney disease. This link can be assumed
since the chronic kidney disease is listed under the subterm "with."
The following example from the Alphabetic Index for the main term Anemia and the
subterm "in" demonstrates the linkage between conditions:
 
        Anemia (essential) (general) (hemoglobin deficiency) (infantile) (primary)
(profound) D64.9
       -in (due to) (with)
       --chronic kidney disease D63.1
       --end stage renal disease D63.1
       --failure, kidney (renal) D63.1
       --neoplastic disease (see also Neoplasm) D63.0
 
The diagnoses of anemia and chronic kidney disease are coded as D63.1, Anemia in
chronic kidney disease. This linkage can be assumed because the chronic kidney
disease is listed under the subterm "in (due to) (with)."

"Due To"
 
     The words "due to" in either the Alphabetic Index or the Tabular List indicate that
a causal relationship between two conditions is present. ICD-10-CM occasionally
makes such an assumption when both conditions are present. In other combinations,
however, the diagnostic statement must indicate this relationship. For example,
certain conditions affecting the mitral valve are assumed to be rheumatic in origin,
regardless of whether or not the diagnostic statement makes this distinction. In other
cases, the Alphabetic Index provides a subterm "due to," which must be followed
when the physician's statement indicates a causal relationship. The coding
professional should be guided by the Index entry.